Critical Care Reviews Newsletter
February 24th 2013
Welcome
Hello
Welcome to the 64th Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.
This week's research studies include yet more evidence that hydroxyethyl starches are harmful, two studies on the new oral anticoagulants, two studies on coronary revascularization and a phase two study investigating a novel anti-sepsis therapy. There are several editorials and commentaries, including a debate on a potential move to a seven day working week. Amongst the 56 review articles highlighted are three papers on a novel topic, psychiatric emergencies, which could present to the intensivist.
The topic for This Week's Papers is complications of transfusion, starting with a paper on transfusion-related acute lung injury in tomorrow's Paper of the Day.
Research
Journal of the American Medical Association: Hydroxyethyl Starch
To evaluate the association of hydroxyethyl starch use with mortality and acute kidney injury, Zarychanski and colleagues performed a systematic review and meta analysis (initially 38 trials with 10,880 patients, refined to 31 trials with 10,290 after the exclusion of retracted trials) comparing hydroxyethyl starch to crystalloids, albumin, or gelatin. The majority of trials were categorized as having an unclear risk or high risk of bias. Excluding the retracted studies, hydroxyethyl starch was associated with increased mortality (relative risk 1.09; 95% CI 1.02 to 1.17; I2 0%; absolute risk 1.51%; 95% CI 0.02% to 3.00%), increased renal failure among 8725 patients (RR 1.27; 95% CI 1.09 to 1.47; I2 26%; AR 5.45%; 95% CI 0.44% to 10.47%), and increased use of renal replacement therapy among 9258 patients (RR 1.32; 95% CI 1.15 to 1.50; I2 0%; AR 3.12%; 95% CI 0.47% to 5.78%). Conclusion: In a systematic review and meta analysis, hydroxyethyl starch administration was associated with increased risks of death, renal failure and renal replacement therapy.
New England Journal of Medicine: Dabigatran
In two double-blind, randomized trials, dabigatran (150 mg twice daily) was compared with warfarin (active-control study) or with placebo (placebo-control study) in patients with venous thromboembolism who had completed at least 3 initial months of therapy. In the active-control study, for rates of recurrent venous thromboembolism, dabigatran (1.8%; 26/1430) was not inferior to warfarin (1.3%; 18/1426) (hazard ratio with dabigatran, 1.44; 95% CI 0.78-2.64; P=0.01 for noninferiority). Similarly, there was no difference in major bleeding; dabigatran group (0.9%, 13/1430) versus warfarin group (1.8%; 25/1426) (hazard ratio 0.52; 95% CI 0.27-1.02), although major or clinically relevant bleeding was less frequent with dabigatran (HR 0.54; 95% CI 0.41-0.71). Acute coronary syndromes were more common in the dabigatran group (0.9%; 13/1430) versus (0.2%; 3/1426) (P=0.02). In the placebo-control study, recurrent venous thromboembolism was less common in the dabigatran group (0.4%; 3/681) than in the placebo group (5.6%; 37/662) (HR 0.08; 95% CI 0.02-0.25; P<0.001). Major or clinically relevant bleeding occurred more frequently in the dabigatran group (5.3%; 36/681) versus (1.8%; 12/662) (HR 2.92; 95% CI 1.52 to 5.60). Acute coronary syndromes occurred in 1 patient each in the dabigatran and placebo groups. Conclusion: Dabigatran was not inferior to warfarin for the extended treatment of venous thromboembolism and carried a lower risk of major or clinically relevant bleeding than warfarin but a higher risk than placebo.
New England Journal of Medicine: Apixiban
Agnelli et al completed a randomized, double-blind study, comparing two doses of apixaban (2.5 mg and 5 mg, twice daily for 12 months) with placebo in 2486 patients with venous thromboembolism who had completed 6 to 12 months of anticoagulation therapy. Symptomatic recurrent venous thromboembolism or death from venous thromboembolism occurred in 8.8% (73/829) in those receiving placebo, 1.7% (14/840) in those receiving apixaban 2.5 mg (a difference of 7.2%; 95% CI 5.0 to 9.3) and 1.7% (14/813) in those receiving 5 mg of apixaban (a difference of 7.0%; 95% CI, 4.9 to 9.1) (P<0.001 for both comparisons). The rates of major bleeding were 0.5% in the placebo group, 0.2% in the 2.5-mg apixaban group, and 0.1% in the 5-mg apixaban group. The rates of clinically relevant nonmajor bleeding were 2.3% in the placebo group, 3.0% in the 2.5-mg apixaban group, and 4.2% in the 5-mg apixaban group. The rate of death from any cause was 1.7% in the placebo group, as compared with 0.8% in the 2.5-mg apixaban group and 0.5% in the 5-mg apixaban group. Conclusions: Extended anticoagulation with apixaban, at either a treatment dose (5 mg) or a thromboprophylactic dose (2.5 mg), reduced the risk of recurrent venous thromboembolism without increasing the rate of major bleeding.
Abstract: Agnelli. Apixaban for Extended Treatment of Venous Thromboembolism. N Engl J Med 2013;368:699-708
The Lancet: Coronary Revascularization
Mohr et al report the 5-year results of the multi-centre, randomized SYNTAX trial, which compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for the treatment of patients with left main coronary disease or three-vessel disease. 1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). Kaplan-Meier estimates of the major endpoint, a composite rate of major adverse cardiac and cerebrovascular events, were higher in the PCI group (37.3 versus 26·9%, p<0·0001). Likewise, estimates of myocardial infarction ( 9·7% versus 3·8%; p<0·0001) and repeat revascularisation (25·9% versus 13·7% vs ; p<0·0001) were significantly increased with PCI versus CABG. Neither all-cause death (PCI group 13·9% versus CABG group 11·4%; p=0·10) nor stroke (PCI group 2.4% versus CABG group 3·7%; p=0·09) were significantly different. In patients with intermediate or high SYNTAX scores, major adverse cardiac and cerebrovascular events was significantly increased with PCI (intermediate score, PCI group 36·0% versus CABG group 25·8%, p=0·008; high score, PCI group 44·0% versus CABG group 26·8%; p<0·0001). Conclusion: CABG is superior to PCI for complex lesions (high or intermediate SYNTAX scores), although for less complex disease (low SYNTAX scores) or left main coronary disease (low or intermediate SYNTAX scores), PCI is an acceptable alternative.
Critical Care Medicine: Sepsis
Guntupalli et al completed a prospective, randomized, double-blind, placebo-controlled, multicenter phase 2 trial, investigating whether enteral lactoferrin (talactoferrin), a glycoprotein with anti-infective and anti-inflammatory properties which contributes to gastrointestinal mucosal barrier integrity, could reduce 28-day all-cause mortality in 194 patients with severe sepsis. The all-cause mortality at 28 days was 26.9% in the placebo group and 14.4% in the talactoferrin group (two-sided p = 0.052), representing a 12.5% absolute and a 46.5% relative reduction in mortality, meeting the protocol-specified primary endpoint. Reduction in all cause mortality was sustained at 6 months (p = 0.039). These reductions in mortality were observed across a wide spectrum of subgroups. The drug was well tolerated with a safety profile similar to that of placebo. Conclusion: Enteral administration of talactoferrin reduced 28-day all-cause mortality in patients with severe sepsis.
JACC Cardiovascular Interventions: PCI post Acute Myocardial Infarction with Cardiac Arrest
Mylotte et al conducted a multicenter prospective observational study to assess the impact of multivessel (MV) primary percutaneous coronary intervention (PCI) on clinical outcomes in 266 patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock and resuscitated cardiac arrest.Patients with single vessel disease (SVD, 36.5%) had increased 6-month survival compared to those with multi-vessel disease (MVD, 29.6% vs. 42.3%, p = 0.032). Baseline characteristics were similar in those with MVD undergoing culprit-only (60.9%) or MV (39.1%) primary PCI. However, 6-month survival was significantly greater in patients who underwent MV PCI (43.9% vs. 20.4%, p = 0.0017). This survival advantage was mediated by a reduction in the composite of recurrent cardiac arrest and death due to shock (p = 0.024) in MV PCI patients. In those with MVD, culprit artery PCI success (hazard ratio 0.63; 95% CI 0.41 to 0.96, p = 0.030) and MV primary PCI (HR 0.57; 95% CI: 0.38 to 0.84, p = 0.005) were associated with increased 6-month survival. Conclusion: Multivessel primary PCI may improve outcomes in patients with STEMI and multivessel disease presenting with cardiogenic shock and cardiac arrest.
Editorial
Journal of Pharmacology & Pharmacotherapeutics: Medical Education
Journal of Toxicology: Medical Writing
Anesthesiology: Haemoglobin
Commentary
British Medical Journal: 7 Day Working Week
- Keogh. Should the NHS work at weekends as it does in the week? Yes. BMJ 2013;346:f621
- Flynn. Should the NHS work at weekends as it does in the week? No. BMJ 2013;346:f622
Journal of the American Medical Association: Tuberculosis
Canadian Medical Association Journal: Microbiome
Review - Clinical
Neurological
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia: Subarachnoid Haemorrhage
Stroke Research and Treatment: Stroke Therapy
Neurology Research International: Cerebral Vasospasm
- Mills. Advanced Imaging Modalities in the Detection of Cerebral Vasospasm. Neurology Research International 2013;2013:415960
- Siasios. Cerebral Vasospasm Pharmacological Treatment: An Update. Neurology Research International 2013;2013:571328
Transfusion: Coagulopathy after Traumatic Brain Injury
Circulatory
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia: Sterno-Mediastinitis
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia: Cardiovascular Perfusion
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia: Coronary Artery Surgery
HSR Proceedings in Intensive Care and Cardiovascular Anesthesia: Thoracic Aortic Surgery
Shock: Nitric Oxide Donor Agents
Experimental and Therapeutic Medicine: Cardiac Stem Cells
Transfusion: Near Infrared Spectroscopy
Cardiology Research and Practice
Respiratory
Anesthesiology: Trauma-Induced Respiratory Failure
Wilderness & Environmental Medicine: Surgical Cricothyroidotomy
Respiratory Care: Modes of Ventilation
Gastrointestinal
Journal of the American College of Surgery: Abdominal Compartment Syndrome
World Journal of Gastroenterology: Acute Pancreatitis
European Review for Medical and Pharmacological Sciences: Intestinal Microbiota
Nutrition
Nutrients: Perioperative Feeding
Nutrients: Feeding the Malnourished Surgical Patient
Nutrients: Nutrition in Burns
Nutrients: Critical Care Nutrition
Hepatobiliary
Journal of the American College of Surgeons: Neuroendocrine Liver Metastasis
Haematological
Transfusion: Massive Transfusion
Transfusion: Traumatic Coagulopathy
- Davenport. Pathogenesis of acute traumatic coagulopathy. Transfusion 2013;53:23S–27S
- Hagemo. Prehospital detection of traumatic coagulopathy. Transfusion 2013;53:48S–51S
Anesthesiology: Perioperative Plasmapheresis
Thrombosis: New Oral Anti-Coagulants
- Tun. Prevention and Treatment of Venous Thromboembolism with New Oral Anticoagulants: A Practical Update for Clinicians. Thrombosis 2013;2013:183616
- Testa. The Role of Anticoagulation Clinics in the Era of New Oral Anticoagulants. Thrombosis 2012;2012:835356
Thrombosis: New Oral Anti-Coagulants for Stroke Prevention
Thrombosis and Haemostasis: Venothromboembolism Prophylaxis
Energency Medicine Journal: Dabigatran
Sepsis
North American Journal of Medical Sciences: New Antibacterials
Seminars in Immunopathology: Staphlococcus Aureus
PLoS Pathogens: Staphlococcus Aureus Leukotoxins
Fungal Biology Reviews: Anti-Fungal Proteins
Trauma
Transfusion: Haemorrhage Control
Transfusion: Damage Control Resuscitation
Transfusion: Microcirculation and Traumatic Coagulopathy
Transfusion: Tranexamic Acid
Toxicology
Shock: Alcohol Abuse
Journal of Natural Science, Biology and Medicine: Bioterrorism
Immunology
Allergy: Mast Cell
Allergy: Churg-Strauss Syndrome
End-of-Life
Journal of Critical Care: Do-Not-Resuscitate
Journal of Critical Care: End-of-Life Decisions
Journal of Critical Care: American Rare Donor Programme
Psychiatry
European Review for Medical and Pharmacological Sciences: Psychiatric Emergencies
- Testa. Psychiatric emergencies (part I): psychiatric disorders causing organic symptoms. Eur Rev Med Pharmacol Sci 2013; 17 (1 Suppl): 55-64
- Testa. Psychiatric emergencies (part II): psychiatric disorders coexisting with organic diseases. Eur Rev Med Pharmacol Sci 2013; 17 (1 Suppl): 65-85
- Testa. Psychiatric emergencies (part III): psychiatric symptoms resulting from organic diseases. Eur Rev Med Pharmacol Sci 2013; 17 (1 Suppl): 86-99
Miscellaneous
Anesthesiology: Situational Awareness
Journal of Pharmacology & Pharmacotherapeutics: Hedgehog Inhibitors
Clinical Cardiology: Paediatric Cardiology
Review - Basic Science
Young Scientists Journal: Stem Cells
Review - Non-Clinical
BMC Medicine: Evidence-Based Medicine
I hope you find these brief summaries and links useful.
Until next week
Rob
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